R-DHAP is a combination chemotherapy treatment used to treat non-Hodgkin lymphoma.
It is best to read this information with our general information about chemotherapy and the type of cancer you have.
R-DHAP comes from the initials of the drugs used:
- R – rituximab
- D – dexamethasone (a steroid)
- HA – high-dose cytarabine (Ara C)
- P – cisplatin (platinum).
Rituximab is not a chemotherapy drug. It is a targeted therapy and belongs to a group of drugs called monoclonal antibodies.
You will be given R-DHAP during a stay in hospital, or you may have it as an outpatient. A chemotherapy nurse will give it to you.
During treatment you usually see a cancer doctor, a blood specialist (haematologist), a chemotherapy nurse or a specialist nurse. This is who we mean when we mention doctor or nurse in this information.
Before or on the day of treatment, a nurse or person trained to take blood (phlebotomist) will take a blood sample from you. This is to check that your blood cells are at a safe level to have chemotherapy.
You will see a doctor or nurse before you have chemotherapy. They will ask you how you have been feeling. If your blood results are okay, the pharmacist will prepare your chemotherapy. Your nurse will tell you when your treatment is likely to be ready.
Your nurse usually gives you anti-sickness (anti-emetic) drugs before the chemotherapy. You will be given extra fluids through a drip before and after cisplatin chemotherapy. This is to protect your kidneys and maintain the balance of salts in your blood. You may also be given a drug called mannitol. Mannitol increases the amount of urine your kidneys make.
The chemotherapy drugs can be given through:
- a fine tube that goes under the skin of your chest and into a vein close by (central line)
- a fine tube that is put into a vein in your arm and goes up into a vein in your chest (PICC line).
The drugs are run through a pump, which gives you the chemotherapy over a set time. You have lots of drugs and fluids given when you have R-DHAP. This means you may have two drips running at the same time.
Dexamethasone is usually given as tablets, but it may be given as a drip (infusion).
Your course of R-DHAP
R-DHAP is given over four days.
On day one, the nurse will give you:
- dexamethasone as tablets or as an infusion
- rituximab as an infusion
- cisplatin as an infusion over 24 hours.
Rituximab can cause a reaction in some people. The nurse will give you drugs to help prevent or reduce this. A reaction is most likely with the first infusion, so it is given slowly over a few hours.
On day two, the nurse will give you:
- dexamethasone as tablets or as an infusion
- cytarabine as two infusions, 12 hours apart. Each infusion is given over 2 to 3 hours.
On days three and four, you continue to have dexamethasone as tablets or as an infusion.
After the four days of treatment, you have a rest period with no treatment for either 17 or 24 days (your doctor will explain which). This completes what is called a cycle of your chemotherapy treatment. Each cycle takes 21 or 28 days (three or four weeks).
At the end of this rest period, you start your second cycle of R-DHAP. This is the same as the first cycle, except your rituximab infusion may be given over a shorter time.
Your doctor or nurse will tell you the number of cycles you are likely to have.
You can usually go home after the first two days of your course of chemotherapy, when you have had all your chemotherapy infusions. Most people then have dexamethasone as tablets. The nurse or pharmacist will give you tablets to take at home, to complete the four days of treatment. You will also be given other drugs to take, to prevent side effects such as sickness. Take all your tablets exactly as the nurse or pharmacist explains.
You will be given steroid eye drops, which help prevent sore eyes. Your doctor or chemotherapy nurse will tell you how and when to use them.
We explain the most common side effects of this treatment here. We also include some less common side effects. You may get some of the side effects we mention, but you are unlikely to get all of them.
You may also have some side effects that we have not listed here. Always tell your doctor, nurse or pharmacist about any side effects you have.
Your doctor can give you drugs to help control some side effects. It is important to take them exactly as your nurse or pharmacist explains. This means they will be more likely to work for you. Your nurse will give you advice about managing your side effects. After your treatment is over, most side effects start to improve.
Serious and life-threatening side effects
Some cancer treatments can cause severe side effects. Rarely, these may be life-threatening. Your cancer doctor or nurse can explain the risk of these side effects to you.
Contact the hospital
Your nurse will give you telephone numbers for the hospital. If you feel unwell or need advice, you can call them at any time of the day or night. Save these numbers in your phone or keep them somewhere safe.
We cannot list every side effect for this treatment. There are some rare side effects that are not listed. You can visit the electronic Medicines Compendium (eMC) to download a Patient Information Leaflet (PIL) for these drugs. The leaflet lists all known side effects.
Some people have an allergic reaction to rituximab while they are having it. A reaction is most likely with the first infusion, so it is given slowly over a few hours. Before treatment, you will be given medicines to help prevent or reduce any reaction.
Signs of a reaction can include:
- feeling hot or flushed
- a skin rash
- feeling dizzy
- a headache
- feeling breathless
- swelling of your face or mouth
- pain in your back, tummy or chest.
Your nurse will check you for signs of a reaction during your infusion. If you feel unwell or have any of these signs, tell them straight away. If you do have a reaction, it can be treated quickly.
Sometimes, a reaction can happen a few hours after treatment. If you develop any signs or feel unwell after you get home, contact the hospital straight away.
The drug leaks outside of the vein
If this happens it can damage the tissue around the vein. This is called extravasation. Extravasation is not common when your drugs are given through a central line or PICC line. But if it happens, it is important that it is dealt with quickly. Tell your nurse straight away if you have any stinging, pain, redness or swelling around the vein.
If you get any of these symptoms after you get home, contact the doctor or nurse straight away on the number they gave you.
Your blood pressure may fall when having rituximab. If you usually take medicine to lower your blood pressure, your doctor may ask you not to take it for 12 hours before having rituximab. Sometimes, rituximab can make your blood pressure go up. Your nurse will check your blood pressure regularly.
During the infusion, some people have mild pain in the parts of the body where they have cancer. Painkillers can be given to help with this.
Reaction to cytarabine
Cytarabine may cause a reaction 6 to 12 hours after it is given. Signs of a reaction can include:
- a high temperature or chills
- a rash
- pain in the eyes, muscles, bones, tummy or chest.
Tell your nurse or contact the hospital straight away if you have any of these symptoms.
Risk of infection
This treatment can reduce the number of white blood cells in your blood. These cells fight infection.
If the number of white blood cells is low, you are more likely to get an infection. A low white blood cell count is called neutropenia.
If you have an infection, it is important to treat it as soon as possible. Contact the hospital straight away on the 24-hour contact number you have if:
- your temperature goes over 37.5°C (99.5°F)
- you suddenly feel unwell, even with a normal temperature
- you have symptoms of an infection.
Symptoms of an infection include:
- feeling shivery
- a sore throat
- a cough
- needing to pass urine often.
It is important to follow any specific advice your cancer treatment team gives you.
The number of white blood cells will usually return to normal before your next treatment. You will have a blood test before having more treatment. If your white blood cell count is low, your doctor may delay your treatment for a short time.
Bruising and bleeding
This treatment can reduce the number of platelets in your blood. Platelets are cells that help the blood to clot.
Tell your doctor if you have any bruising or bleeding that you cannot explain. This includes:
- bleeding gums
- tiny red or purple spots on the skin that may look like a rash.
Some people may need a drip to give them extra platelets. This is called a platelet transfusion.
Anaemia (low number of red blood cells)
This treatment can reduce the number of red blood cells in your blood. These cells carry oxygen around the body. If the number of red blood cells is low, you may be tired and breathless. Tell your doctor or nurse if you feel like this. If you are very anaemic, you may need a drip to give you extra red blood cells. This is called a blood transfusion.
You may feel sick in the first few days after this treatment. Your doctor will give you anti-sickness drugs to help prevent or control sickness. Take the drugs exactly as your nurse or pharmacist tells you. It is easier to prevent sickness than to treat it after it has started.
If you feel sick, take small sips of fluids and eat small amounts often. If you continue to feel sick, or if you vomit more than once in 24-hours, contact the hospital as soon as possible. They will give you advice and may change the anti-sickness drug to one that works better for you.
Feeling tired is a common side effect. It is often worse towards the end of treatment and for some weeks after it has finished. Try to pace yourself and plan your day so you have time to rest. Gentle exercise, like short walks, can give you more energy. If you feel sleepy, do not drive or operate machinery.
You may get a sore mouth or mouth ulcers. This can make you more likely to get a mouth infection.
Use a soft toothbrush to clean your teeth or dentures in the morning, at night and after meals.
If your mouth is sore:
- tell your nurse or doctor – they can give you a mouthwash or medicines to help
- try to drink plenty of fluids
- avoid alcohol, tobacco, and foods that irritate your mouth.
Loss of appetite
This treatment can affect your appetite. Do not worry if you do not eat much for a day or two. But if your appetite does not come back after a few days, tell your nurse or dietitian. They will give you advice. They may give you food or drink supplements.
Effects on the eyes
This treatment may make your eyes feel sore, red and itchy (conjunctivitis). Your doctor may prescribe eye drops to help prevent this. It is important to use these as you are told to.
This treatment may also make your eyes more sensitive to light and cause blurred vision. If you have pain or notice any change in your vision, always tell your doctor or nurse.
Do not wear contact lenses if you are using eye drops or if your eyes are sore. Your doctor can tell you when you can wear them again.
If you have diarrhoea, contact the hospital for advice. Try to drink at least 2 litres (3½ pints) of fluids every day. It can help to avoid alcohol, caffeine, milk products, high-fat foods and high-fibre foods.
Cisplatin can affect your hearing. You may have a hearing test before you start treatment. You may get ringing in your ears (tinnitus) and become unable to hear some high-pitched sounds.
Tinnitus usually gets better after treatment ends. Some hearing changes can be permanent. Tell your doctor if you notice any changes in your hearing.
R-DHAP can cause a rash on your skin, which may be itchy. You may also notice unusual feelings in your skin such as numbness, tingling, pricking or burning. Rarely, skin reactions can be more severe.
Tell your doctor or nurse about any skin changes. They can give you advice and may give you creams or medicines to help. Any changes to your skin are usually temporary and improve when treatment finishes.
Soreness and redness of palms of hands and soles of feet
This is called palmar-plantar or hand-foot syndrome. Your doctor or nurse can give you advice and prescribe creams to improve the symptoms. It can help to keep your hands and feet cool and to avoid tight-fitting socks, shoes and gloves. It will start to get better when treatment ends.
Build-up of fluid (oedema)
You may put on weight, or your ankles and legs may swell because of fluid building up. Tell your doctor or nurse if fluid builds up. If your ankles and legs swell, it can help to put your legs up on a foot stool or cushion. The swelling gets better after treatment ends.
Muscle or joint pain
You may get pain in your muscles or joints for a few days after treatment. If this happens, tell your doctor so they can give you painkillers. Tell them if the pain does not get better. Having warm baths and taking regular rests may help.
Effects on the nervous system
R-DHAP can affect the nervous system. You may feel anxious or restless, have problems sleeping or experience mood changes. You may feel drowsy, confused, dizzy or unsteady. Tell your doctor or nurse straight away if you notice any of these symptoms. Rarely, this treatment can cause seizures (fits).
Effects on the kidneys
Cisplatin can affect how your kidneys work. You will have blood tests before and during treatment to check this.
Before and after each treatment, your nurses will give you extra fluids through a drip. This is to protect your kidneys. It is also important to drink at least 2 litres (3½ pints) of fluids each day.
If you pass less urine than usual, tell your nurse.
Effects on the liver
This treatment may affect how your liver works. This is usually mild and goes back to normal after treatment. You will have blood tests to check how well your liver is working.
Raised blood sugar levels
Steroids can raise your blood sugar levels. Your nurse will check your blood sugar regularly for this. They may also test your urine for sugar. Symptoms of raised blood sugar include:
- feeling thirsty
- needing to pass urine often
- feeling tired.
Tell your doctor or nurse if you have these symptoms.
If you have diabetes, your blood sugar levels may be higher than usual. Your doctor will talk to you about how to manage this. You may need to adjust your insulin or tablet dose.
Raised levels of uric acid (tumour lysis syndrome)
This treatment may cause the cancer cells to break down quickly. This releases uric acid (a waste product) into the blood. The kidneys usually get rid of uric acid but may not be able cope with large amounts. Too much uric acid can cause swelling and pain in the joints (gout).
Your doctor may give you allopurinol tablets to help prevent this. Drinking at least 2 litres (3½ pints) of fluid a day will also help. You will have regular blood tests to check the uric acid levels.
Numb or tingling hands or feet (peripheral neuropathy)
This treatment affects the nerves, which can cause numb, tingling or painful hands or feet. You may find it hard to fasten buttons or do other fiddly tasks.
Tell your doctor if you have these symptoms. They sometimes need to lower the dose of the drug. The symptoms usually improve slowly after treatment finishes, but for some people they may never go away. Talk to your doctor if you are worried about this.
Your hair will get thinner or you may lose all the hair from your head. You may also lose your eyelashes, eyebrows or other body hair. Hair loss usually starts after your first or second treatment.
Your nurse can talk to you about ways to cope with hair loss. There are ways to cover up hair loss if you want to. It is important to cover your head to protect your scalp when you are out in the sun.
Hair loss is almost always temporary and your hair will usually grow back after treatment ends.
Tummy pain or indigestion
Steroids can irritate the stomach lining. Tell your doctor or nurse if you have pain in your tummy (abdomen) or indigestion. They can give you drugs to help reduce stomach irritation. Take your tablets with food to help protect your stomach.
Effects on the heart
Chemotherapy can affect the way the heart works. You may have tests to see how well your heart is working. These may be done before, during, and sometimes after treatment. If the treatment is causing heart problems, your doctor can change the type of chemotherapy you are having.
Contact a doctor straight away if you:
- have pain or tightness in your chest
- feel breathless or dizzy
- feel your heart is beating too fast or too slowly.
Other conditions can cause these symptoms, but it is important to get them checked by a doctor.
Effects on the lungs
This treatment can cause changes to the lungs. Tell your doctor if you develop:
- a cough
- a fever (high temperature)
You should also tell them if any existing breathing problems get worse. You may have tests to check your lungs.
Blood clot risk
Cancer and some cancer treatments can increase the risk of a blood clot. Symptoms of a blood clot include:
- pain, redness or swelling in a leg or arm
- chest pain.
If you have any of these symptoms, contact a doctor straight away.
A blood clot is serious, but can be treated with drugs that thin the blood. Your doctor or nurse can give you more information.
Do not drive if you feel dizzy or tired, or if your vision is affected. Talk to your doctor if you are not sure whether it is safe for you to drive.
Hepatitis B reactivation
If you have had hepatitis B (a liver infection) in the past, rituximab can make it active again. Your doctor or nurse will talk to you about this and test you for hepatitis B. If you have active hepatitis B, you will not have treatment with rituximab.
You should avoid having live vaccines during treatment and for at least 6 months afterwards. Your doctor can talk to you about vaccines.
Some medicines can affect your treatment or be harmful when you are having it. This includes medicines you can buy in a shop or chemist. Tell your cancer doctor about any drugs you are taking, including vitamins, herbal drugs and complementary therapies.
Your doctor will advise you not to get pregnant or make someone pregnant while having this treatment and for some time afterwards. The drugs may harm the developing baby. It is important to use effective contraception.
Women are advised not to breastfeed while having this treatment. This is because the drugs could be passed to the baby through breast milk.
This treatment can affect if you can get pregnant or make someone pregnant.
If you are a woman, your periods may become irregular or stop. This may be temporary, but for some women it is permanent. Your menopause may start sooner than it would have done.
If you have sex in the first few days after chemotherapy, you need to use a condom. This is to protect your partner in case there is any chemotherapy in semen or vaginal fluids.
Changes to your periods
R-DHAP can sometimes stop the ovaries working. You might not get a period every month and they may eventually stop. In some women this is temporary, but for others it is permanent and they start the menopause.
Medical and dental treatment
If you need medical treatment for any reason other than cancer, always tell the doctors and nurses that you are having cancer treatment. Give them the contact details for your cancer doctor so they can ask for advice.
If you think you need dental treatment, talk to your cancer doctor or nurse. Always tell your dentist you are having cancer treatment.